Provider Demographics
NPI:1003952334
Name:BOUDREAU, RICHARD GEORGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GEORGE
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13160 MINDANAO WAY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6358
Mailing Address - Country:US
Mailing Address - Phone:310-822-6161
Mailing Address - Fax:310-822-6825
Practice Address - Street 1:13160 MINDANAO WAY
Practice Address - Street 2:SUITE 120
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6358
Practice Address - Country:US
Practice Address - Phone:310-822-6161
Practice Address - Fax:310-822-6825
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD218521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery